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Going Global

The Going Global blog is an opportunity for emergency physicians to share their experiences practicing and teaching outside the United States. Submit an article about your experience to EMN at emn@lww.com. Be sure to include a brief biography and photographs of the authors. Photos taken during time spent abroad are also welcome, and should be 300 dpi and in jpg, tif, or gif format.

This blog was started by the emergency medicine residents of Palmetto Health Richland in Columbia, SC, who travel the globe on medical missions. The program is under the direction of Thomas Cook, MD, who oversees one of more than 40 academic departments of emergency medicine that sponsors Global International Emergency Medicine Fellowships.

Friday, December 21, 2018

Bringing Emergency Medicine to Eswatini

BY ADERONKE SUSAN AKAPO, DO; KATHLEEN ANNE ROCCO, MD; EDWARD KAKISH, DO; & KRIS BRICKMAN, MD

Eswatini, known as Swaziland until April 2018, is a small South African country approximately the size of New Jersey. It has 1.3 million people, and is bordered by South Africa and Mozambique.

The country primarily comprises rural tribal areas with two major cities, Manzini and Mbabane, in the central portion of the country. Eswatini holds the unfortunate distinction of having the highest HIV rate in the world—approximately 26 percent of its population. Emergency medicine within this small country is clearly in its developmental stages—it is not recognized as a specialty, nor are there any training programs or requirements for emergency departments.

Roger Pachalka, MD, an emergency physician from Wright State University in Dayton, OH, initiated collaborative efforts with representatives from the University of Toledo's global health program and the department of emergency medicine along with pediatric physicians from Nationwide Children's Hospital. All were invited to meet with the Eswatini Ministry of Health in January 2018 to address the development of emergency medicine within the country. This initial exploratory visit and several meetings with the Ministry of Health and hospital officials at Raleigh Fitkin Memorial Hospital and Mbabane Government Hospital identified the need to develop a triage system, establish a true prioritization process to separate emergency department patients from outpatient clinic patients, and create emergency care standards that could be accepted throughout the country.

These efforts resulted in the development of the first provider conference for emergency medicine in Manzini in July. More than 130 prehospital personnel, nurses, physicians, and administrators traveled up to 120 miles to attend this introduction to emergency medicine.

The most prevalent emergent health care concerns identified in previous studies of Swaziland after HIV/AIDS include trauma care, infectious diarrheal disease, respiratory infections, tuberculosis, and stroke. Health care resources in Eswatini remain quite poor in spite of adequate literacy rates exceeding 85 percent and a middle-income population for Africa. Resources for appropriate trauma management, acute medical emergencies including cardiovascular and neurologic problems, and vascular access for managing dehydration and acute infectious diseases are quite limited. A major concern is the lack of a medical school within a country with a very limited number of physician resources. This, combined with the absence of a triage system, limited equipment and monitors, and limited ancillary support, indicates that the emergency care system of the country has opportunities for improvement.

This conference focused on the areas where we felt education and training could make an impact. Our Ohio-based faculty and residents from the University of Toledo Medical Center, Nationwide Children's Hospital, and Wright State University provided education and training on developing triage systems, adult and pediatric resuscitation stabilization, trauma care, and vascular access. The hands-on workshop component of the conference incorporated interosseous infusion education and training, pediatric and adult CPR resuscitation, and identification of cardiac arrhythmias. This was the first emergency medicine conference in Eswatini, and attendees said it was highly beneficial and educational.

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Eswatini medical professionals practicing basic life support.

This educational effort was also an academic experience for the emergency medicine residency at the University of Toledo Medical Center. Faculty and two EM residents were involved in developing and delivering this symposium. Global health has been a hallmark of Toledo's emergency medicine residency with initiatives in Central America, Africa, the Middle East, China, and Southwest Asia.

Further support, development, and resources for emergency medicine from the Ministry of Health will be necessary to achieve the goals of a state-of-the-art emergency care system within the country. We came away confident that the health care providers within the country are highly intelligent and fully capable of delivering a high level of emergency care if a standardized emergency care system can be supported by the local hospitals and the government. The initial starting point should be establishing triage systems at all hospitals in the country.

As EM residents, this experience in global health education and development was invaluable to us. It provided us a new perspective on health care and the opportunities for emergency care in other countries. We learned about the importance of honing our clinical skills and how to better utilize resources in patient care. We are grateful for the exposure to a cost-effective health care practice model that is essentially the norm outside of the United States where health care resources must be managed with appropriate restraint.


Dr. Brickman demonstrates the technique to obtain emergent intraosseous vascular access.

We hope to continue this relationship with the Eswatini health care teams to improve health care delivery and a long-term goal of establishing a true emergency medicine specialty in Eswatini that may be a model throughout Africa. This experience to participate in the health care system of a country at the local and national levels and in developing emergency medicine has become an invaluable part of our education.

Looking forward, our team is planning to return to Eswatini in six months to assess the development of the strategic mission that has been laid out for the country in standardizing emergency medicine. We have established ongoing communications between government and administrative officials at the hospitals to collaborate on the initiatives. We are highly encouraged by the response to this initial education and training effort, and are hopeful upon our return that we will find the bar for emergency care within the country higher than we left it.

Dr. Akapo and Dr. Rocco are second-year emergency medicine residents at the University of Toledo. Dr. Kakish is an assistant professor and the program director of the emergency medicine residency program, and Dr. Brickman is a professor and the chairman of emergency medicine and the director of the global health program there.